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Lymphadenektomie bei Tumoren des oberen Gastrointestinaltraktes

Lymphadenectomy with tumors of the upper gastrointestinal tract

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Zusammenfassung

Eine adäquate Lymphadenektomie stellt zusammen mit einer R0-Resektion des Primärtumors einen der wichtigsten technisch beeinflussbaren Prognoseparameter bei der chirurgischen Behandlung von Karzinomen des oberen Gastrointestinaltrakts dar. Auf der Basis histopathologisch-anatomischer Untersuchungen an Patientenkollektiven großer Zentren lassen sich Empfehlungen für eine lokalisations- und stadiengerechte Lymphadenektomie aufstellen.

Nach neoadjuvanter Radiochemotherapie zervikaler Ösophaguskarzinome hat der Nachweis fehlender Lymphknoten am Präparat eine geringere prognostische Bedeutung. Bei den suprabifurkalen Plattenepithelkarzinomen ist besonders bei frühen Befunden eine radikale Lymphadenektomie zu empfehlen. Für das infrabifurkal gelegene Ösophaguskarzinom ist die 2-Feld-Lymphadenektomie im Rahmen der sog. Ivor-Lewis-Operation die Methode der Wahl. Fortgeschrittene Barrett-Karzinome profitieren ebenfalls von einer systematischen Lymphadenektomie, jedoch mit Erweiterung um die retroperitonealen Lymphabflusswege zum linken Nierenstiel. Submukosakarzinome in diesem Bereich können als Ausnahme mit einer luminal limitierten Resektion des ösophagogastralen Übergangs zusammen mit einer adäquaten Lymphadenektomie therapiert werden. Für Adenokarzinome der Kardia sowie subkardiale Magenkarzinome mit Kardiainfiltration ist die Lymphadenektomie analog der Magenkarzinome unter Berücksichtigung der retroperitonealen Lymphabflusswege zum linken Nierenstiel notwendig. Zur Therapie des Magenkarzinoms sollte immer eine systematische D2-Lymphadenektomie durchgeführt werden.

Abstract

In surgical therapy for upper gastrointestinal cancer, adequate lymphadenectomy together with R0 resection of the primary tumour is one of the most important prognostic factors which can be influenced by the surgeon. Recommendations for localization- and stage-adapted lymphadenectomy can be made according to histopathologic and anatomic investigations of the patient collectives of large centres. After neoadjuvant radiochemotherapy in cancer of the cervical oesophagus, the absence of lymph nodes on the resected specimen seems to be of less prognostic value. In squamous cell cancer of the suprabifurcal oesophagus, radical lymphadenectomy is recommended. Despite significant morbidity, in specialized centres this procedure yields good results with low mortality. For infrabifurcal oesophageal cancer, two-field lymphadenectomy during the so-called Ivor-Lewis operation is the method of choice. Locally advanced Barrett carcinoma is also an indication for classic two-field lymphadenectomy together with abdominothoracic oesophagectomy and creation of a stomach tube with intrathoracic anastomosis. The lymphadenectomy should however include the area of retroperitoneal lymphatic drainage at the pedicle of the left kidney. Submucosal cancer in this area can be treated with luminal limited resection of the oesophagogastric junction with adequate lymphadenectomy. Adenocarcinoma of the cardia and subcardial gastric cancer including the cardia both require lymphadenectomy analogous to that performed in gastric cancer, with special attention paid to the retroperitoneal lymphatic drainage towards the left kidney pedicle. For therapy of gastric cancer, a systematic D2 lymphadenectomy should always be performed.

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Authors and Affiliations

  1. Chirurgische Klinik der TU München, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Deutschland

    C. Schuhmacher, A. Novotny, K. Ott, M. Feith & J.R. Siewert

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  1. C. Schuhmacher
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  2. A. Novotny
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  3. K. Ott
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  4. M. Feith
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  5. J.R. Siewert
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Correspondence to C. Schuhmacher.

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Schuhmacher, C., Novotny, A., Ott, K. et al. Lymphadenektomie bei Tumoren des oberen Gastrointestinaltraktes. Chirurg 78, 203–216 (2007). https://doi.org/10.1007/s00104-007-1307-7

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